With an aging population, nonagenarians (≥90 years of age) are increasingly being considered for cardiac catheterization. Because of the paucity of outcomes data in this population, we sought to evaluate the acute and intermediate outcomes of nonagenarians undergoing cardiac catheterization. A retrospective cohort of 44 nonagenarians undergoing 53 cardiac catheterizations from 2002 to 2010 was identified. Mean age was 91 years (range 90 to 96) with 57% of patients being women. Thirteen percent presented with ST-segment elevation myocardial infarction, 32% with non–ST-segment elevation myocardial infarction, 14% with unstable angina, 25% with chronic angina, and 16% with aortic stenosis. Eighteen percent had left main coronary artery disease and 73% had multivessel coronary disease. Complications occurred in 6 of 44 patients (3 with acute kidney injury, 2 with atrial fibrillation, 1 with femoral artery pseudoaneurysm). Twenty patients were treated with medical management, 1 patient underwent coronary artery bypass surgery, and 2 patients underwent aortic valve replacement. Twenty-one patients underwent percutaneous coronary intervention in 27 different vessels. There was procedural success in 93% of these patients. There were no major adverse cardiac events. Five complications occurred after the intervention (4 atrial fibrillations, 1 femoral artery pseudoaneurysm). Cumulative mortalities at 1 month and 6 and 12 months were 0%, 9%, and 20% respectively. In patients who underwent percutaneous coronary intervention or surgery, mortalities were 0%, 0%, and 13% at 1 month and 6 and 12 months, respectively.
The very elderly are the fastest growing segment of the United States population. Heart disease remains the number 1 cause of death in the elderly, with an even greater burden of disease affecting the very elderly. Despite this we have few data on the risks and benefits of current management guidelines when applied to nonagenarians. Nonagenarians with an acute coronary syndrome are more likely to die or develop an adverse event in the hospital even after adjusting for baseline characteristics. There are few available studies examining the outcome of very elderly patients referred for cardiac catheterization and potential revascularization in the modern era. The goal of this study was to evaluate short-term risks and benefits associated with cardiac catheterization and subsequent therapeutic procedures in patients ≥90 years old.
Methods
We performed a retrospective analysis of the Thomas Jefferson University Hospital medical and electronic records from March 2002 through July 2010 for all patients ≥90 years old who underwent cardiac catheterization. Overall, 44 nonagenarians undergoing 53 cardiac catheterization procedures were included in the analysis.
All data were obtained using standardized case-report forms. Data included demographic information, baseline clinical characteristics, laboratory values, details of invasive cardiac procedures, in-hospital outcomes, procedural complications, and length of stay. Postprocedure mortality data were collected using the Social Security Death Index.
A subset of patients underwent 2 catheterizations, and in all cases the first represented a diagnostic procedure and the second involved a percutaneous coronary intervention (PCI). These interventions were recorded as 2 separate procedures. Procedural success was defined as ≤20% residual angiographic stenosis by visual estimate or by Thrombolysis In Myocardial Infarction scale flow grade 3. Myocardial infarction was defined by the inclusion of ≥2 of the following 3 clinical features: ischemic chest pain, significant changes on electrocardiogram, or increase of serum troponin level. This was further classified as ST-segment elevation myocardial infarction if electrocardiogram showed ≥1 mm ST-segment elevation in ≥2 contiguous leads or new left bundle branch block. Stroke was defined as a new focal neurologic deficit lasting >24 hours. Acute kidney injury was defined as ≥30% increase in baseline creatinine within 72 hours of catheterization. Hyperlipidemia was defined as a patient-reported history of receiving treatment for an abnormal lipid level. Possible vascular complications included pseudoaneurysm, thrombosis, and clinically significant bleed (defined as new or worsening anemia clinically attributable to a suspected bleeding source, intracranial hemorrhage, or retroperitoneal hemorrhage). We received approval from the institutional review board of Thomas Jefferson University Hospital to collect these data and publish our findings.
Assessment of PCI outcome was made by visual estimation. PCI was performed by standard percutaneous techniques. Choices regarding anticoagulation, glycoprotein IIb/IIIa inhibitors, and type of intervention were based on the operator’s judgment. Categorical variables are displayed as frequency and corresponding percentage. Continuous data are presented as mean ± SD.
Results
During the study period 53 cardiac catheterizations were performed in 44 patients ≥90 years of age. Mean age was 91 years (range 90 to 96), 57% were women, and 93% were white. The remainder of the baseline characteristics is presented in Table 1 . Thirty-six percent of patients had a history of myocardial infarction, 25% had valvular heart disease (20% had aortic stenosis and 5% had mitral regurgitation). Eighteen percent had previous PCI and 16% had previous coronary artery bypass grafting (CABG).
| Variable | |
|---|---|
| African-American | 2 (5%) |
| Hispanic-American | 1 (2%) |
| Body mass index (kg/m 2 ) | 24.92 (13.7–35.1) |
| Diabetes mellitus | 8 (18%) |
| Previous stroke | 9 (20%) |
| Cancer | 7 (16%) |
| Hypertension | 36 (82%) |
| Pulmonary disease | 4 (9%) |
| Peripheral vascular disease | 8 (18%) |
| Heart failure | 9 (20%) |
| Atrial fibrillation | 13 (30%) |
| Former smoker | 16 (36%) |
| Alcohol use | 17 (39%) |
| Thyroid disease | 7 (16%) |
| Laboratory results | |
| Leukocyte count (×10 9 /L) | 8.1 ± 4.8 |
| Platelet count (×10 9 /L) | 233 ± 119.3 |
| Hemoglobin <10 (g/dl) | 5 (11%) |
Mean baseline hemoglobin was 11.7 ± 4.8 g/dl and mean creatinine was 1.2 ± 0.4 mg/dl. Eleven percent of patients had a measured glomerular filtration rate <30 ml/min/1.73 m 2 . Lipid analysis showed a mean low-density lipoprotein of 100.4 ± 42.7 mg/dl, a mean high-density lipoprotein of 42.2 ± 11.4 mg/dl, and a mean triglyceride level of 42.2 ± 11.4 mg/dl. Thirty-two percent of patients presented with troponin I >0.5 ng/ml (range <0.05 to 95.2), 11% with hemoglobin <10 g/dl, and 7% with an international normalized ratio >1.5. Other laboratory values are listed in Table 1 . Fourteen percent of patients presented with ST-segment elevation myocardial infarction, 32% with non–ST-segment myocardial infarction, 25% with chronic angina, 14% with unstable angina pectoris, and 16% with aortic stenosis. No patients presented in cardiogenic shock.
Overall, 73% of nonagenarians had multivessel coronary disease with 59% having 3-vessel coronary disease. Eighteen percent of patients were found to have left main coronary artery disease, 64% had left anterior descending artery disease, 59% had right coronary artery disease, and 41% had left circumflex coronary artery disease. In the subset of patients with aortic stenosis as an indication, 3 of 6 had 3-vessel coronary disease and none of the 6 underwent PCI or CABG. Based on angiographic findings, 21 patients subsequently underwent PCI in 27 different vessels. There was procedural success in 93% of attempted interventions. One patient underwent CABG, 2 patients underwent aortic valve replacement, and the remainder received medical management.
Complications occurred in 6 of 23 patients (3 with acute kidney injury, 2 with atrial fibrillation, 1 with pseudoaneurysm) after diagnostic cardiac catheterization. After the intervention, 5 of 21 patients developed a complication (4 atrial fibrillations, 1 pseudoaneurysm). In all cases of acute kidney injury, renal function returned to baseline with aggressive hydration. The 2 patients with pseudoaneurysm were managed conservatively without surgical intervention. Cases of postprocedure atrial fibrillation represented a new onset for each patient, with each reverting to normal sinus rhythm before discharge. There were no major adverse cardiac events before discharge such as stroke, myocardial infarction, or cardiac death. In patients who subsequently underwent medical management, mortality was 0% at 1 month, 20% (4 of 20) at 6 months, and 30% (6 of 20) at 12 months. In patients who underwent PCI or a cardiac surgical procedure, mortality was 0% at 1 month and 6 months and 13% (3 of 24) at 12 months. Overall mortality was 0% at 1 month, 9% at 6 months, and 20% at 12 months.
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